Current through all regulations passed and filed through September 16, 2024
(A) Responsibility
(1) When the hearing decision orders action
to be taken by the agency, the agency that is ordered to take the action is
responsible for promptly and fully implementing the decision.
(2) State hearings is responsible for
monitoring timely compliance with decisions.
(3) When the hearing decision orders action
to be taken by a managed care plan or "MyCare Ohio" plan, the managed care plan
or "MyCare Ohio" plan is responsible for promptly and fully implementing the
decision.
The Ohio department of medicaid (ODM) is responsible for timely
compliance with decisions involving compliance by a managed care plan or
"MyCare Ohio" plan.
(B) Promptness
(1) Decisions that order action favorable to
the individual
(a) For decisions involving
public assistance, social services or child support services, compliance shall
be achieved within fifteen calendar days from the date the decision is issued,
but in no event later than ninety calendar days from the date of the hearing
request.
(b) For decisions
involving
the supplemental nutrition assistance program
(SNAP), any increase in benefits must be reflected in the
SNAP allotment within ten calendar days of receipt of
the decision, even if the local agency must provide a supplement, outside the
normal issuance cycle.
The local agency may take longer than ten days if it elects to
make the decision effective in the assistance group's normal issuance cycle,
provided that issuance will occur within sixty calendar days of the date of the
hearing request. If the local agency elects to follow this procedure, the
benefit increase may be reflected in the normal issuance cycle or with a
supplementary issuance.
(c)
Compliance shall be promptly reported to the bureau of state hearings, via a
notice certifying the agency's compliance with the state hearing decision and
accompanied by appropriate documentation substantiating compliance is met.
When the hearing decision orders action to be taken by a
managed care plan or a "MyCare Ohio" plan, each shall also send a copy of the
notice certifying the agency's compliance with the state hearing decision, to
ODM.
(2)
Decisions that authorize action adverse to the individual
(a) The agency shall implement the decision
promptly, if still appropriate.
(b)
When the adverse action results in a decrease in the assistance group's
SNAP benefits, the decrease shall be reflected in the
next issuance cycle following receipt of the hearing decision.
(C) Date compliance is
achieved
(1) For decisions involving public
assistance, social services or child support services, compliance shall be
considered achieved on the date eligibility, payment, or services are
authorized or other action ordered by the hearing decision is taken.
(2) For decisions involving
SNAP, compliance shall be considered achieved on the
date the action is reflected in the assistance group's
SNAP allotment.
(D) Underpayments/
under
issuances
(1) When the decision
determines that the individual has been improperly denied benefits or has
received fewer benefits than were due, any underpayments must be corrected in
accordance with rules
5101:1-23-60
and/or 5101:4-8-03 of the
Administrative Code.
(2) The local
agency shall restore
SNAP benefits to assistance groups that are
leaving the county before the departure whenever possible. If benefits are not
restored prior to departure, the local agency shall forward an authorization of
the benefits to the assistance group or to the new county if this information
is known.
The new county shall accept an authorization and issue the
appropriate benefits whether the notice is presented by the assistance group or
received directly from another county.
(E) Overpayments/
over
issuances
(1) Overpayments related to
the appeal are subject to collection in accordance with rule
5101:1-23-70 of the
Administrative Code.
(2) When the
appeal involves
SNAP, a claim against the assistance group for
any
over issuance related to the appeal must be prepared
in accordance with rule
5101:4-8-15 of the
Administrative Code.
(F)
Prior authorization issues
(1) When a hearing
decision reverses a denial of prior authorization for medical service and
authorizes the service, the approval unit shall approve the prior
authorization, using the normal prior authorization procedure. The approval
notification sent to the provider shall be accompanied by a copy of the hearing
decision.
(2) When a hearing
decision reverses a denial of prior authorization for additional therapeutic
leave days for a medicaid recipient with a developmental disabilities (DD)
level of care in a long-term care facility, the bureau of state hearings shall
send a copy of the decision to the long-term care facility. The hearing
decision constitutes authorization for the additional leave days.
(G) Precertification issues
When a hearing decision changes a review agency's decision on a
request for precertification of a hospital admission or medical procedure, the
bureau of state hearings shall send a copy of the decision and a notice
certifying the agency's compliance with the state hearing decision to the
review agency.
The review agency shall certify those hospital days or medical
procedures authorized by the decision using the normal precertification
procedure, complete the notice certifying the agency's compliance with the
state hearing decision, and send it to state hearings.
(H) Coordinated services program (CSP) issues
When a hearing decision changes a decision by the recipient
monitoring and review section concerning proposed or continued enrollment in
the CSP or denial of a request for a change of designated provider, the bureau
of state hearings shall send a copy of the decision to the recipient monitoring
and review section. The recipient monitoring and review section shall take the
actions ordered by the decision, complete the notice certifying the agency's
compliance with the state hearing decision, and send it to state
hearings.
(I) Preadmission
screening resident review (PASRR) issues
When a hearing decision changes a preadmission screening (PAS)
or resident review (RR) determination made by the Ohio department of mental
health and addiction services or the Ohio department of developmental
disabilities, the hearing decision shall constitute the revised PAS or RR
determination.
